Provider Demographics
NPI:1477034841
Name:STILLSON, JACOB ANDREW
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ANDREW
Last Name:STILLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3960 MAYFIELD AVE NE APT 2A
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6612
Mailing Address - Country:US
Mailing Address - Phone:231-286-4528
Mailing Address - Fax:
Practice Address - Street 1:1428 44TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-4312
Practice Address - Country:US
Practice Address - Phone:616-604-8492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician